ACL Injuries in Children and Adolescents
Children are not simply “small adults.” Anatomically and physiologically, they differ from adults in many ways. Knee injuries in children and adolescents frequently reflect these differences.
- The primary difference between an adult and child knee is the presence of growth centers, or physes. These are regions at the end of the femur and tibia on both sides of the knee. They are responsible for most of the leg’s growth.
- The physes are usually the weakest part of the knee. An injury pattern that would tear a ligament or cartilage in a mature adult knee is more likely to result in a fracture through the growth center in a child’s knee.
“Adult” type knee injuries can occur in a child. Anterior cruciate ligament (ACL) tears were once thought to be extremely rare in children but have received more attention in recent years. This is largely due to greater participation in competitive sports, improved physician awareness, and advances in diagnostic techniques such as MRI and arthroscopy.
The true occurrence of ACL tears in the pediatric population is unknown, but multiple studies suggest a steady increase over the past two decades, especially among adolescent girls participating in high-risk sports like soccer and basketball that involve deceleration, pivoting or change of direction.
A child may describe feeling a ‘pop’ at the time of injury, and swelling of the knee is common within six hours.
Knee Injuries
Access additional causes, symptoms and treatment information.
How Are ACL Injuries Treated?
Non-operative treatment with braces and exercise usually fails. These patients frequently experience episodes of instability or “giving way,” which can lead to additional injuries such as meniscal tears. This may lead to premature arthritis later in life.
In skeletally mature adolescents with ACL tears, treatment typically involves surgical reconstruction. A tendon is usually taken from another part of the body and used to rebuild the torn ligament.
Reconstruction usually involves placing the tendon graft through drill holes in the femur and tibia. Unfortunately for younger patients, the growth centers in the knee are directly in the path of these drill holes. Standard reconstruction in the growing child or adolescent may cause growth abnormalities, leading to leg length inequality or angulatory deformity at the knee. The younger the child, the greater the chance and severity of these deformities.
If the adolescent is within a year or two of skeletal maturity, most physicians feel the risks are small, and a standard ACL reconstruction is usually performed. For younger patients, alternative techniques have been developed recently to try to lessen the possibilities of growth arrest.
These techniques involve placing the graft in a non-anatomic position that does not fully duplicate normal ligament function. This is done by either drilling holes that go around rather than through the growth centers, or by avoiding holes altogether, and wrapping the graft around the bone.
Originally intended as temporary measures to manage symptoms and instability until skeletal maturity, these procedures have shown promising results—with reported return to sports rates consistently above 90%.
Consult your primary care physician for more serious injuries that do not respond to basic first aid. As an added resource, the staff at Nationwide Children’s Hospital Sports Medicine is available to diagnose and treat sports-related injuries for youth or adolescent athletes. Services are available in multiple locations. To make an appointment, call (614) 355-6000 or schedule an appointment online.
Medical Reviewer: Drew H. Duerson, MD, Nationwide Children's Hospital
Date Last Reviewed: 10/27/2025
Sources & Publications:
- Napolitano J, Duerson D, MacDonald J. Anterior Cruciate Ligament Injuries in Female Athletes. JAMA. 2024 Jul 25
The information provided here is only for general reference and should not take the place of medical care or patient education. If you have any questions, please call your child's care team.